Patient Placement Criteria: Linking Typologies to Managed Care.

The proliferation of managed health care systems as a means of controlling rising health care costs has stimulated efforts to subdivide the heterogeneous population of alcoholics into more homogeneous subgroups based on their needs for specific levels of treatment. The American Society of Addiction Medicine (ASAM) has developed a set of criteria aimed at helping clinicians select from four levels of care the one most appropriate for each patient. The ASAM criteria are designed around six criteria dimensions reflecting the severity of the patients alcohol-related problems. Although the ASAM criteria currently are the most widely used placement criteria for alcoholism treatment and reimbursement, they also have been criticized in several respects. Moreover, they still require outcome validation to ensure that application of the criteria improves treatment outcome.


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or many years, alcoholism treat alcoholrelated problems.Furthermore, treating alcohol and other drug (AOD) ment providers predominantly as most researchers now believe that no abuse in both the private and public sumed that people with drinking single form of treatment is effective sectors, the demand for specific types problems 1 were a homogeneous group for all people presenting with alcohol or levels of treatment (e.g., inpatient that could be treated optimally with related problems (Hester and Miller detoxification or residential rehabili only one treatment modality.This 1989).Consequently, alcohol researchers tation) now depends on more than just modality involved inpatient care with now are conducting many studies de the patient's wishes or the physician's a fixed length of stay and a treatment signed to determine what types of in perceptions of what the patient needs.approach based on the 12step model terventions are most effective for what Patients now must meet utilization re of Alcoholics Anonymous.In recent types of patients.This approach is view criteria set by the managed care years, however, both assumptions-founded on the "matching hypothesis," providers in order to be eligible for that of patient homogeneity and treat which states that an optimal matching of treatment reimbursement.In addition ment uniformity-have been abandoned.patients and treatments will produce the to controlling costs, the development As the articles in this journal issue il greatest overall treatment effectiveness. of such criteria will enable health care lustrate, researchers and clinicians now The need to acknowledge formally delivery systems to account for mean recognize that problem drinkers are a the heterogeneity of treatment needs ingful and valid differences among diverse group and differ substantially among people with alcoholrelated prob problem drinkers and to determine in the causes and manifestations of their lems recently has received additional more accurately the mix of treatment impetus from a direction unanticipated 1 In this article, the terms "people with drinking prob when the subtyping of alcoholics first LESLIE C. MOREY, PH.D., is a visiting lems" and "problem drinkers" refer to all individuals became popular-namely, from the associate professor of psychology at whose alcohol consumption has caused them medical, proliferation of managed care systems Harvard Medical School, Boston, Mas psychological, or social problems.These overarching as a means of controlling health care sachusetts, and an associate professor terms therefore encompass the more medical diagnoses of alcohol abuse and alcohol dependence as defined by costs (see sidebar, p. 38.).With the of psychology at Vanderbilt University, the American Psychiatric Association.
widespread use of managed care in Nashville, Tennessee.
services the patients need.Ultimately, the improved match between patient needs and the types of services avail able within the system will enhance the efficiency and effectiveness of the alcoholism treatment system.This matching process likely will focus on selecting specific treatment modalities rather than on the settings in which these modalities are provided.This article reviews the influences that led to the development of patient placement criteria as well as the process involved in designing such criteria.It summarizes the placement criteria de veloped by the American Society of Addiction Medicine (ASAM), which currently are the most widely used cri teria, and presents both their advantages and disadvantages.Finally, the article describes the relationships of patient placement criteria with typological ap proaches based on patient characteristics.

THE NEED FOR PATIENT TREATMENT MATCHING
As researchers and clinicians began to explore the heterogeneity of individuals with drinking problems, their interest in differences between the various modal ities and settings for treating alcohol related problems also increased.One issue that stimulated much discussion concerned the merits of inpatient treat ment for alcoholrelated problems, and several studies concluded that inpatient treatment programs for alcoholism were no more effective than formal outpa tient programs (Miller and Hester 1986;Annis 1986;Saxe and Good man 1988).This conclusion forced the alcoholism treatment community to reexamine many of the basic assump tions that for years had dominated treatment programs.
The findings particularly raised questions about the costeffectiveness of prevailing treatments.For example, Hayashida and colleagues (1989) dem onstrated that inpatient detoxification of patients with mild to moderate features of alcohol withdrawal was no more ef fective than outpatient detoxification but costed approximately 10 times more.These results should be inter preted cautiously, however, because the study also found that treatment completion rates were higher in the inpatient program (95 percent) than in the outpatient program (72 percent).
Thus, although the overall effec tiveness of inpatient care generally is accepted (Finney and Moos 1991;Walsh et al. 1991), concerns exist that this more costly approach has been applied to many patients who did not require this level of care.Moreover, aside from the actual dollar costs of treatment, other costs with potential clinical implications may be associated with inappropriate patienttreatment matching.For example, inpatient care disrupts the patient's family life, em ployment, and social activities far more than does outpatient treatment.
The increasing influence of managed health care also has greatly stimulated patienttreatment matching considera tions.In particular, managed care pro viders introduced utilization reviews that base treatment decisions on the patients' abilities to meet certain cri teria.The requirement for such reviews provided a significant challenge for the alcohol field, because until recently no criteria existed that had achieved widespread acceptance.The need to develop patient placement criteria prompted researchers, clinicians, and service providers to examine more closely existing alcoholism treatment modalities and their appropriateness for various subgroups of people with drinking problems.

THE EVOLUTION OF PATIENT PLACEMENT CRITERIA
As managed care became increasingly popular for both publicly and privately funded alcoholism treatment, insurance companies and various State agencies began to establish criteria to determine the appropriate placement or level of care for AOD abusers.These standards differed widely, however, and were often kept secret to prevent providers from slanting patient information in an effort to obtain more favorable out comes during utilization review.In 1987 two organizations published guidelines that represented the initial steps toward generating more widely applicable criteria for establishing treatment based typologies of problem drinkers.The Northern Ohio Chemical Depen dency Treatment Directors Associ ation developed a set of guidelines known as the "Cleveland criteria" (Hoffman et al. 1987) that used rat ings in a variety of life areas to gauge the appropriateness of six levels of care.These levels ranged from mutual selfhelp groups to medically managed intensive inpatient units.The second organization, the National Association of Addiction Treatment Providers (NAATP), independently developed a similar set of criteria (Weedman 1987).
Many experts who were involved in developing these two criteria sets also participated in task forces estab lished under ASAM's direction.These task forces developed a set of patient placement criteria that integrated and revised various features of both the Cleveland criteria and the NAATP cri teria.These new guidelines, now called the ASAM criteria, were published by ASAM in a volume entitled Patient Placement Criteria for the Treatment of Psychoactive Substance Use Dis orders (Hoffman et al. 1991).The cri teria provide guidelines not only for alcoholism treatment but also for other forms of drug abuse and dependence.

The ASAM Criteria
The ASAM criteria were developed from numerous and widely dissemi nated drafts and revisions and were

MANAGED HEALTH CARE
The rapid development of managed care systems has resulted in sweeping changes in the U.S. health care system, including alcoholism treatment.Although the forerunners of such systems date back to the 1920's (MacLeod 1993), the modern development of managed care accelerated during the 1970's, stimu lated by the private sector in response to years of unchecked inflation in health care costs and by widespread resistance to the concept of a national health in surance.The passage of both the Health Maintenance Organization Act in 1973, which required minimal benefits for alcohol and other drug abuse treatment, and subsequent amendments facilitated the expansion of the corporate practice of medicine.Large enrollment health care programs developed through new means of financing.These programs proliferated, with the expectation that competition between different programs would help contain health care costs with minimal government intervention.
One outgrowth of this movement was a major shift in the financing of health care.In many cases, individual feeforservice payments were replaced by one prepayment covering services provided to each subscriber in the sys tem for a specified period.This process is known as "capitation."Under these new plans, health care providers had to bear part of the financial risk in provid ing services-for example, if providers incurred expenses exceeding the budg eted estimates, they had to absorb the deficit.This financing structure pro vided strong incentives to reduce hospital care and shift services to less expensive outpatient settings.
The term "managed" in "managed care" refers in part to the control that payers (i.e., insurance companies or health maintenance organizations) exert over health care decisions (e.g., which services an individual patient should use) in an effort to contain costs while ensuring adequate quality of care.This control often is accomplished through utilization reviews that include pre admission certification of patients for in patient care and concurrent reviews of patients in inpatient/residential care (and sometimes outpatient care) to determine whether the particular level of care is medically necessary.This process re quires using placement criteria that clearly specify the requirements that pa tients must meet to be admitted to the various levels of care offered within the program.This requirement for placement criteria, however, significantly chal lenges the alcohol field, because to date no universally accepted criteria exist.

REFERENCE
MacLeod, G.K.An overview of managed health care.In: Kongstvedt, P.R., ed.The Managed Health Care Handbook.Gaithersburg, MD: Aspen Publishers, 1993.
evaluated in field tests at 15 different sites (MeeLee 1993).The primary goal of the criteria was to provide a common language for both providers and payers when determining the severity of a pa tient's problems, the different levels or settings of the treatment modalities offered, and the criteria for patient placement within the continuum of AOD treatment.These criteria not only described patient characteristics that might warrant inpatient care but also provided guidelines for different types of outpatient treatment and outlined the process of moving across different levels of care.
The ASAM system is built around criteria dimensions that are used to place patients in one of four levels of care originally presented in an Institute of Medicine report (1990) describing transitions in the alcoholism treat ment field.The four levels of care are as follows: • Level I: Outpatient treatment.
Such settings include organized nonresidential services or office practices in permanent facilities with designated addiction treat ment personnel who provide pro fessionally directed evaluation, treatment, and recovery services to addicted patients.The services are provided in regularly scheduled sessions of usually fewer than 9 hours per week.
• Level II: Intensive outpatient and partial hospitalization treatment.In these settings, an organized service with designated addiction personnel provides a planned treatment regi men consisting of regularly sched uled sessions of at least 9 hours per week within a structured program.This level of care affords patients the opportunity to interact with the realworld environment while still benefiting from a programmatically structured therapeutic milieu.
These modalities, which are of fered in permanent facilities with inpatient beds, include a planned regimen of roundtheclock profes sionally directed evaluation, care, and treatment for addicted patients provided by designated addiction personnel.The treatment is specific to AOD abuse and does not require the full resources of an acutecare general hospital.
• Level IV: Medically managed in patient treatment.This level of care, which also is administered by de signated addiction professionals, provides a roundtheclock planned regimen of medically directed eval uation, care, and treatment for ad dicted patients in an acutecare inpatient setting.Such a service requires permanent facilities that include, at a minimum, inpatient beds.A multidisciplinary staff and the full resources of a general hos pital are available to provide treat ment for patients with severe acute problems necessitating primary medical and nursing services.Treat ment is specific to AODuse disor ders, although the available support services allow concurrent treat ment of coexisting acute biomedi cal and emotional conditions.
Under the ASAM guidelines, pa tients are assigned to the four levels of care after being evaluated along six criteria dimensions reflecting the sever ity of the patients' problems.Each di mension contains several criteria, and the number of specific criteria that must be met depends on the level of care.These six dimensions are described in the following paragraphs.
Dimension 1: Acute Intoxication and/or Withdrawal Potential.The ASAM criteria assume that a person who is acutely intoxicated cannot be monitored adequately as an outpatient and should receive more intensive care.When assessing withdrawal potential, one of the most important considera tions is whether the patient is at risk of experiencing lifethreatening with drawal symptoms or requires medica tion or other support services to cope with or reduce the discomfort of with drawal, which otherwise might cause him or her to terminate treatment.
Dimension 2: Biomedical Condi tions or Complications.Higher levels of care are indicated when continued AOD use would put the patient in dan ger of health complications.For ex ample, an alcoholdependent woman who is pregnant might benefit from a higher level of care.Similarly, problem drinkers with cardiovascular, liver, or gastrointestinal diseases requiring med ical monitoring or treatment should receive a higher level of care.

Dimension 3: Emotional and Behavioral Conditions and Compli cations.
A wide range of emotional and behavioral conditions and com plications exist in problem drinkers, either as manifestations of alcohol abuse or as independent, coexisting psychiatric disorders.These conditions (e.g., debilitating anxiety, guilt, or de pression) deserve special attention during treatment and therefore may necessitate a higher level of clinical care.Moreover, problem drinkers ex hibiting signs of an imminent risk of harming themselves (e.g., attempting to commit suicide) or others may re quire 24hour monitoring, thus justify ing a higher level of clinical care.The same holds true for problem drinkers whose mental status does not allow them to understand the nature of the disorder or the treatment process.
Dimension 4: Treatment Acceptance/Resistance.Patients in alcoholism treatment vary greatly in their willingness to comply with treat ment regimens.Patients who seek treatment and cooperate by following clinical instructions typically require Patients are assigned to the four levels of care after being evaluated along six criteria dimensions.
a lower level of care.However, alco hol dependence often compromises a person's capacity to cooperate with treatment protocols.Patients often present for treatment with some level of understanding that alcohol is re sponsible for their alcohol problems but are still unwilling to participate in the clinical process.Other patients may deny that they have a drinking problem.Thus, some problem drinkers may be unlikely to enter the treatment system without first receiving some form of therapeutic preparation directed at addressing their denial and their resis tance to treatment.Under these condi tions, a high level of clinical care may be appropriate.
Dimension 5: Relapse Potential.Because alcoholrelated problems in volve recurrent patterns of behavior, relapse is a frequent and integral part of the natural history of the disorder.Two major sets of factors that derive from the patient's personal (i.e., psy chological and biological) background and social environment contribute to relapse potential.This dimension ad dresses the personal factors that influ ence the extent to which people can control their environments.(Environ mental factors are addressed in di mension 6.) Accordingly, when these elements impede a patient's control over his or her behavior in the current environment, a higher level of care (e.g., a halfway house rather than out patient care) may be justified to mini mize the relapse risk.For example, if a patient experiences marked and per sistent cravings for alcohol and thus has higher relapse potential, treatment success may be less likely in an outpa tient than in an inpatient setting.
Dimension 6: Recovery Environ ment.The patient's environment can facilitate recovery or increase the risk of relapse.When the social setting is supportive (e.g., family members and friends agree with and encourage re covery) or the patient seeks out social surroundings that discourage alcohol abusing behavior patterns, a lower level of clinical care may be justified.How ever, when a recovering person's social setting is compromised-for example, by inadequate transportation to the treatment provider, a higher level of family stress, or friends and cowork ers who regularly use alcohol-a higher level of care may be required.
Table 1 summarizes the correlations between the treatment settings and criteria dimensions specified by the ASAM guidelines.The actual criteria for placing an individual into a given level of care vary according to the care level, and placement ultimately de pends on the combination of patient characteristics in the six assessment dimensions.For example, treatment in an outpatient setting (i.e., level I) requires that the patient meets level I criteria in all six assessment dimen sions, whereas treatment in an inpa tient setting (i.e., level III or IV) requires that the patient meets the corresponding severity criteria in at least two of the six dimensions.Fur thermore, not all dimensions are rele vant to all placement decisions.For example, treatment resistance, relapse

ADVANTAGES AND DISADVANTAGES OF THE ASAM CRITERIA
The ASAM criteria have become the most widely distributed and discussed criteria available, and several States have used them or some of their adap tations as guidelines for patient place ment and medicaid reimbursement.Many aspects of the ASAM criteria make them reasonably well suited for such use.First, the criteria were de veloped by a multidisciplinary con sensus group, including physicians, social workers, psychologists, and substance abuse counselors.Perhaps because of this comprehensive input, the dimensions composing the criteria relate to actual patient dispositions as well as to treatment dropout (Gastfriend et al. 1995).Second, the criteria have achieved much national visibility, far exceeding the impact of other criteria sets.Third, the ASAM guidelines sep arately consider factors influencing care for adults and for adolescents.This is important because the social factors associated with a need for higher treatment intensity may vary depending on age.Finally, the criteria specify guidelines for a broader con tinuum of care than traditionally found in the alcoholism treatment field.For example, the criteria include guide lines for continued treatment at each level of care as well as for discharge eligibility.Thus, the ASAM criteria are among the few treatmentmatching guidelines flexible enough to respond to changes in a patient's status during the course of treatment.
Although the ASAM criteria cur rently are the most widely used pa tient placement criteria for treatment and reimbursement in the addiction field, they also have been criticized in several respects (Book et al. 1995;Gartner and MeeLee 1995).For ex ample, relatively few studies to date have assessed the validity of the ASAM criteria, and although relevant projects currently are under way, no evidence yet exists that matching patients to treatments based on the ASAM criteria actually improves treatment outcome.
In the most relevant study, McKay and colleagues (1992) examined the validity of the Cleveland criteria, which were a precursor to the ASAM guide lines.The researchers studied alco holic and cocainedependent patients who were treated in a day treatment program (i.e., ASAM level II).As sessment according to the Cleveland criteria revealed that 76 percent of these patients should have been as signed to inpatient rehabilitation (i.e., level III).The assumptions underlying the ASAM criteria would predict that patients who were "mismatched" to the level of care they received should have had poorer outcomes than those who were appropriately matched.How ever, the study found no differences in outcomes between matched and mis matched patients.Although the mis matched group drank slightly more frequently than the matched group be fore they entered treatment-consistent with the conclusion that severity of problem drinking is related to patient placement decisions resulting from the application of these criteria-the two groups did not differ significantly in their frequency alcohol use after 4 or 7month followup.Overall, all subjects appeared to respond well to treatment regardless of whether they were matched or mismatched accord ing to patient placement criteria.
McKay and colleagues (1992) con cluded that the Cleveland criteria may be overinclusive in identifying patients who require inpatient treatment.Simi lar criticism has been raised against the ASAM criteria, in part because the continuum of care represented in these guidelines does not include some im portant alternatives to traditional in patient care (e.g., halfway houses or therapeutic communities).Other re searchers have expressed concerns that the ASAM criteria overemphasize the medical elements of treatment and con sistently place patients in higher levels of care than needed (Book et al. 1995).
The ASAM criteria also have been criticized for assuming that a linear re lationship exists between the severity of the alcoholrelated problems and the treatment level needed.For example, Book and colleagues (1995) indicate that in some patients, very severe prob lems (e.g., cognitive impairment or marked resistance to treatment) would impair their ability to benefit from ex pensive residential treatments.Conse quently, these writers recommend that individuals who either are not yet ready for such treatments or not able to real ize the benefits of residential treatment be treated in less expensive settings, such as halfway houses.
Other critics of the ASAM guide lines have noted significant conceptual and empirical gaps in the criteria, such as the lack of provisions for prevention

Large alcoholism treatment "campuses" might deliver different types of services all with
in one setting.
and/or early intervention efforts (Gart ner and MeeLee 1995).Moreover, the criteria do not cover several "sublevels" within each ASAM level.For example, intensive outpatient treatment and par tial hospitalization (both regarded as ASAM level II) clearly differ in terms of treatment intensity.Similarly, half way houses, therapeutic communities, and shortterm intensive rehabilitation centers, which all can be considered residential treatment programs (i.e., ASAM level III), may vary widely in terms of treatment intensity.
Other gaps involve patient types rather than types of treatment settings.For example, Morey (1995) found that after strict application of the ASAM criteria, as many as 13 percent of in dividuals who met the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Re vised (DSM-III-R) for alcohol abuse or dependence did not meet the criteria for any of the four levels specified by ASAM.For instance, the ASAM guide lines commonly failed to include prob lem drinkers who were at risk for a problematic withdrawal but manifested no other biological, emotional, or psy chosocial complications.These people did not meet the ASAM criteria for either outpatient treatment, because of their potentially complicated detoxifi cation, or inpatient treatment (i.e., level III), which require problems in at least two of the six domains.Consequently, these patients were excluded from both outpatient and inpatient care.

RELATIONSHIPS OF PATIENT PLACEMENT CRITERIA TO OTHER TYPOLOGICAL APPROACHES
Unlike most of the earlier alcoholism typologies that were based on patient characteristics, the typologies inspired by the managed care movement focus on service systems.In other words, the traditional approach to subtyping people with drinking problems has involved identifying presumably fundamental differences among problem drinkers, followed by attempts to identify the most effective treatment for each sub type.In contrast, the managed care inspired typologies have focused on critical differences between the vari ous forms of treatment, with a partic ular emphasis on the costs of different treatment approaches.In the interests of costcontainment and optimal allo cation of resources, managed care has sought to develop patient placement criteria that restrict the most expen sive forms of treatment-particularly inpatient services-to those patients who need them.The resulting subtyp ing strategy is treatment driven and typically arranged around treatment intensity.Consequently, these typolo gies often bear little resemblance to the typologies described elsewhere in this journal issue.
The common denominator under lying patient placement typologies as well as many other patientbased ty pologies is general problem severity.Although the ASAM criteria them selves are multidimensional, the types of problems described across the six dimensions tend to be interrelated, and most studies demonstrate significant correlations between the level of care recommended according to the ASAM guidelines and global problem severity.For example, McKay and colleagues (1992) found a greater degree of psy chological disturbance as measured by the Addiction Severity Index among patients identified as needing inpatient treatments than among those suited for outpatient treatment.
In a study assessing the applicability of the ASAM criteria in a community sample, Morey (1995) used the guide lines to estimate level of care needs in a household survey of more than 18,000 people, roughly 6.5 percent of whom met the DSM-III-R diagnostic criteria for current alcohol abuse or dependence.The study related the number of alco hol dependence criteria met by the re spondents (out of a possible nine) to the ASAM care levels that would have been assigned to these people.The re sults demonstrated that the number of dependence features reported by re spondents who would have been as signed to inpatient treatments was considerably greater than for respon dents who would have been assigned to outpatient treatment (figure 1).In fact, the respondents identified as needing intensive hospital care (i.e., ASAM level IV) on average fulfilled nearly seven DSM-III-R criteria, in dicating severe dependence according to that diagnostic scheme.
The ASAM criteria's focus on global problem severity when making placement decisions emphasizes quan titative differences among problem drinkers (i.e., people with more severe problems require greater treatment in tensity).Many of the other alcoholism typologies, in contrast, have focused on qualitative differences (e.g., Clon inger's type I versus type II classifi cation or Babor's type A versus type B classification; for more information on these other typologies, see the arti cles by Babor,and by Clon inger and colleagues,.A review of the literature justifies care ful consideration of the quantitative ap proach, which dates back to Jellinek's four phases in the development of al coholism that fell along a severity con tinuum (Jellinek 1962).Subsequent research has supported the contentions that features of alcohol dependence tend to form a unidimensional scale and that the cumulative severity of these dependence problems can pre dict relapse as well as posttreatment craving in abstinent individuals (Babor et al. 1988).This dimensional approach also forms the basis of the DSM-III-R definition of alcoholdependence syn drome with its subdivisions of mild, moderate, and severe forms.Subtyping alcoholics along a continuum of alcohol dependence severity therefore will capture many important differences among people with drinking problems.An exclusive focus on dependence severity, however, may overlook critical qualitative differences among problem drinkers that might assist in tailoring treatment approaches, particularly those offered within a given level of care.
To avoid such a onesided focus, Morey and colleagues (1984) developed the "hybrid" model, combining the quantitative and qualitative models of alcoholrelated problems (figure 2).
(For more information on this typology and how it was derived, see the article by Allen, This typology distinguishes three types of people with drinking problems: lateonset problem drinkers, affiliative/impulsive alcoholics, and isolative/anxious alcoholics.The lateonset problem drinkers demon strate significant signs of alcohol abuse but develop only mild manifestations of the alcoholdependence syndrome.According to the ASAM criteria, nearly all these patients could be treated in outpatient programs.Lateonset problem drinkers differ quantitatively in their problem severity from the affiliative/ impulsive and isolative/anxious alco holics, who both are at an advanced level of alcohol dependence.Con versely, the latter two types differ qualitatively from each other with re spect to interpersonal style, personality traits, concomitant symptoms of mental

Patient Placement Criteria
The hybrid model of alcoholic subtypes.This model distinguishes three categories of alcoholics: late-onset problem drinkers, affiliative/impulsive alcoholics, and isolative/anxious alcoholics.Late-onset problem drinkers diff The hybrid model of alcoholic subtypes.This model distinguishes three categories of alcoholics: late-onset problem drinkers, affiliative/impulsive alcoholics, and isolative/anxious alcoholics.Late-onset problem drinkers differ in the severity of alcoholism (i.e., quantitatively) from drinkers in the other two categories.Affiliative/impulsive alcoholics and isolative/anxious alcoholics differ in certain personal characteristics (i.e., qualitatively) from each other.er in the severity of alcoholism (i.e., quantitatively) from drinkers in the other two categories.Affiliative/impulsive alcoholics and isolative/anxious alcoholics differ in certain personal characteristics (i.e., qualitatively) from each other.

CURRENT STATUS OF PATIENT PLACEMENT CRITERIA
The use of criteria, such as the ASAM standards, for guiding patients into dif ferent forms of treatment is a relatively new development in a rapidly evolv ing field.Although the ASAM cri teria have been disseminated widely in the 5 years since their publication, they have not been uniformly accepted in either the public or private service de livery sector.Several States have re vised the criteria to include treatment modalities that are not well covered by the ASAM guidelines (e.g., meth adone maintenance for treating heroin addiction).Furthermore, the patient placement criteria used by managed care companies tend to be more re strictive than the ASAM guidelines regarding access to the more intensive levels of care (Book et al. 1995).These companies also typically separate the level II services outlined in the ASAM criteria, with partial hospitalization regarded as more intensive treatment with more extensive patient contact than intensive outpatient programs and therefore suitable for patients with greater problem severity.
A review of the current status of pa tient placement criteria by a consensus panel organized by the Center for Sub tance Abuse Treatment (CSAT) sug gested that the future acceptance of uniform patient placement criteria will hinge on several critical issues (Gartner and MeeLee 1995): • The criteria should accurately reflect the different levels of care available.
• The criteria should have documented validity regarding recommended placement levels.
• The criteria should be easy to use in daytoday clinical decisionmaking.
• The criteria should be measurable using reliable and objective tools.
• The criteria should encourage positive treatment outcomes by recommending treatments in the least restrictive environments.
• The criteria should optimally match patients to specific treatment modal ities and levels of care.
The last point is particularly im portant because it addresses what is perceived as the inflexibility of current patient placement criteria.The CSAT panel recommended to "unbundle" the guidelines for the modality and inten sity of treatment from the setting in which treatment is provided.Un bundling means that the type and in tensity of treatment are based more on the patient's needs than on the setting in which they are provided; thus, psy chiatric consultation could be offered in outpatient as well as inpatient set tings, or intensive outpatient treatment could be offered in conjunction with a halfwayhouse setting.For example, large alcoholism treatment "campuses" might deliver different types of ser vices all within one setting.Similarly, McGee (1995) has described a "human service matrix" in which the intensity of social support services needed (e.g., housing needs, child care, community support services, and occupational or legal assistance) is considered indepen dently of the intensity of the clinical services provided (e.g., counseling or psychotherapy, nursing, or biomedical interventions).Separating some of the elements that appear inherently included in prevailing views of certain treatment settings would allow a much greater matching of specific interventions to different types of individual problems.

CONCLUSIONS
Managed care undoubtedly has changed the alcoholism treatment field dramat ically, and its influence will likely only increase in the near future.Although many concerns have been voiced about the effects of managed care on treat ment, this new form of health care delivery presents extraordinary oppor tunities for research results to directly affect clinical practice.Managed care offers strong incentives to match pa tients with alcohol problems to the appropriate levels and types of treat ment services, a goal that alcohol re searchers have been striving to attain for the past two decades.Inherent in this movement will be a greater em phasis on evaluating outcome in differ ent treatments.The array of data that will be collected in this area should help elucidate the fundamental distinc tions among problem drinkers that are most relevant to treatment planning.Despite their outward-and, to some extent, concurrent-validity, however, placement criteria, such as the ASAM guideline, still require outcome valida tion to ensure that they are indeed re lated to differential treatment outcomes.
Concurrently, the evolution of pa tient placement criteria could be en hanced by carefully considering and integrating existing guidelines with the results of typological research.As the alcoholism treatment field moves toward unbundling treatment modali ties from treatment settings, it also must understand the qualitative differ ences between individuals who may need treatments of similar intensity but with differing emphases.The literature on the subtyping of alcoholics includes numerous typologies that have assem bled impressive evidence of validity.Ultimately, managed care may repre sent a means by which typologies dem onstrating validity in the realm of treatment outcome can substantially influence alcoholism treatment prac tices in this country.■ Type II/type B alcoholism illustrated in "Skid Row Bum." Original artwork for "Temp erance Tales and the Alcoholic," 1979.Re produced with permission from the Journal of Studies on Alcohol.© Alcohol Research Documentation, Inc., Rutgers University Center of Alcohol Studies.

Figure 1
Figure 1Figure1The correlation between the level of care of alcoholism treatment and the severity of the patients' alcohol dependence.Based on telephone interviews with approximately 1,150 subjects from a community sample who met the criteria of theThe correlation between the level of care of alcoholism treatment and the severity of the patients' alcohol dependence.Based on telephone interviews with approximately 1,150 subjects from a community sample who met the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) for alcohol abuse and dependence, the researchers assessed the subjects' severity of alcohol dependence and the level of care 1 that they should receive during treatment.Dependence sever (DSM-III-R) for alcohol abuse and dependence, the researchers assessed the subjects' severity of alcohol dependence and the level of care 1 that they should receive during treatment.Dependence severity was indicated by the mean number of DSM-III-R criteria (of which nine were possible) that the subjects met.1 Level of care was determined according to the guidelines established by the Amer ity was indicated by the mean number of DSM-III-R criteria (of which nine were possible) that the subjects met. 1 Level of care was determined according to the guidelines established by the American Society of Addiction Medicine.F = 38.14, ican Society of Addiction Medicine.F = 38.14, p p < 0.001.SOURCE: Adapted from Morey 1995.< 0.001.SOURCE: Adapted from Morey 1995.

Table 1
Summary of the ASAM 1 Criteria Dimensions of Assessment 1 ASAM = American Society of Addiction Medicine.